Healthcare Provider Details

I. General information

NPI: 1104156033
Provider Name (Legal Business Name): C.G. ELLIOTT FOUCAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2009
Last Update Date: 12/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14029 WIND MOUNTAIN RD NE
ALBUQUERQUE NM
87112-6564
US

IV. Provider business mailing address

14029 WIND MOUNTAIN RD NE
ALBUQUERQUE NM
87112-6564
US

V. Phone/Fax

Practice location:
  • Phone: 505-275-1395
  • Fax: 595-275-1395
Mailing address:
  • Phone: 505-275-1395
  • Fax: 595-275-1395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number74-29
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number74-29
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: